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Tuesday, September 7, 2010

Pain & Symptom Management Updates

From the Pharmacist Letter, September 2010:

PAIN


New Canadian guidelines will clarify how to manage opioid therapy in patients with chronic non-cancer pain.

Opioid use is rising and so are abuse, diversion, and overdoses.

But on the other hand, chronic pain is still often undertreated and can lead to disability, depression, and other problems.

Recommend trying other options first, such as NSAIDs for inflammation, low-dose amitriptyline for neuropathic pain, etc.

Before going to chronic opioids, suggest assessing for substance abuse, getting informed consent, and setting up an opioid agreement.

Use pain severity and functional improvement to guide therapy.

Mild to moderate pain. Suggest codeine or tramadol first...then morphine, oxycodone, or hydromorphone if needed.

Recommend starting with a short-acting opioid...titrating the dose as needed...then switching to a long-acting formulation for maintenance to improve adherence and minimize breakthrough pain.

Suggest BuTrans (buprenorphine) for patients who can benefit from a once-a-week patch for moderate pain.

Severe pain. Recommend starting with morphine, oxycodone, or hydromorphone...and stepping up to fentanyl if needed.

Reserve methadone for the most resistant cases. Keep in mind that physicians need a special exemption to prescribe methadone.

Keep an eye on oral morphine equivalents...most patients can be managed on less than 200 mg/day. At higher doses, re-evaluate for tolerance, abuse, or a new cause for the pain. For help, see our chart, Equianalgesic Dosing of Opioids for Pain Management.

Suggest continuing NSAIDs or acetaminophen if they help.

Caution patients to limit acetaminophen doses. Consider recommending a maximum of just 2.6 g/day...instead of 4 g/day...to reduce the risk of developing liver toxicity.

Suggest stopping benzodiazepines before starting opioids...to decrease the risk of sedation and overdose.

Help patients have realistic expectations. Explain that a successful outcome is improving function and reducing pain intensity by about 30%. Also recommend exercise, physical therapy, and adequate rest.

Watch for possible interactions. Oxycodone levels may be increased by 3A4 inhibitors, such as clarithromycin. See our chart, Cytochrome P450 Drug Interactions, for other possible interactions.

View Detail-Document #260909
 
Tools for risk assessment, patient consent, pain contracts, and monitoring are available at:


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Pharmacy History

"The earliest known compilation of medicinal substances was ARIANA the Sushruta Samhita, an Indian Ayurvedic treatise attributed to Sushruta in the 6th century BC. However, the earliest text as preserved dates to the 3rd or 4th century AD.
Many Sumerian (late 6th millennium BC - early 2nd millennium BC) cuneiform clay tablets record prescriptions for medicine.[3]

Ancient Egyptian pharmacological knowledge was recorded in various papyri such as the Ebers Papyrus of 1550 BC, and the Edwin Smith Papyrus of the 16th century BC.

The earliest known Chinese manual on materia medica is the Shennong Bencao Jing (The Divine Farmer's Herb-Root Classic), dating back to the 1st century AD. It was compiled during the Han dynasty and was attributed to the mythical Shennong. Earlier literature included lists of prescriptions for specific ailments, exemplified by a manuscript "Recipes for 52 Ailments", found in the Mawangdui tomb, sealed in 168 BC. Further details on Chinese pharmacy can be found in the Pharmacy in China article."

From Wikipedia: http://en.wikipedia.org/wiki/Pharmacy#History_of_pharmacy

Journal of Palliative Medicine - Table of Contents

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